First, one should briefly summarize the critical area of UHC’s professional activities discussed in this report. This company provides American citizens with counseling and health insurance plans, including Medicare and Medicaid (About us, n.d.). UHC positions itself as a socially responsible organization because its range of professional activities includes supporting vulnerable groups and providing high-quality health care services with increased accessibility. However, clinics often have problems, called HACs, that result in additional damage to a patient’s health at the fault of the hospital. UHC does not cover this plan because its corporate policies are designed to meet the legislative standards of DRA 2005, IPPS FY 2009, and Section 3025 of the PPACA (HRRP, 2020; Hospital-acquired conditions, 2020; HHC, 2013). These acts impose severe limitations on reimbursement to clinics for HACs and HAIs. To put it another way, insurance companies (including UHC) should not cover reasonably preventable acts of harm to a patient’s health because the blame in these scenarios is imposed on physician error and negligence (UHC, 2021). However, UHC also uses other methods to influence clinics, such as through fines on reimbursable patient charges if clinical entities have HAIs greater than a set threshold (Richardson, 2015). To put it another way, if a hospital has many cases of HACs/HAIs, UHC imposes a 1% penalty. However, the data handled is entirely confidential, and it is ruled out that UHC will release the names of those patients who have been subjected to medical errors. This personal security rule is postulated by HIPAA, which also governs UHC. As a generalization, it is pertinent to note that UHC satisfies the regulatory requirement well and creates a culture in which clinics find themselves interested in providing the best care for patients. On the other hand, the insurance organization shows a high level of social responsibility, which means it truly values its clients.
At the same time, it should be understood that health policy is not conservative but strives to follow the current agenda precisely. Therefore, it is very likely to expect that the listed regulatory requirements will modify depending on the development of the risk management problem. On the one hand, if the number of HACs continues to trend upward, this will lead to the establishment of larger sizes and impose more stringent requirements on the operation of clinical organizations. On the other hand, if the number of HACs declines because of constructive policies, we should expect a relaxation of conditions. Finally, in-depth medical research may lead to a broadening/shrinking of the range of HACs for which insurance coverage is actual.
Strategies to Influence, Impact & Monitor Changes
For UHC, there seems to be an apparent interest in reducing the number of HACs. For this reason, the company can use several metrics that will most fully and comprehensively reflect the situation in the healthcare system as a whole, as well as in individual clinics. First and foremost, it is the total number of HACs/HAIs for individual clinics and by region: this statistic will not only help determine how effectively healthcare professionals are coping with their professional tasks but also clarify the average agenda in the region. Information by region can be valuable in determining the need for cultural re-education. On the other hand, information on the proportion of patients (in the hospital) who fall ill because of HACs can help determine how often medical error occurs in a hospital in patient flow. It is also helpful to estimate the amount of money that is reimbursed to a patient if HAC has been included in the 14 exclusion lists (UHC, 2021). This cross-sectional information will provide insight into how often a hospital is found to be innocent of HACs. Finally, a systematic assessment of client satisfaction with the resolution of the problem and their awareness of their rights in relation to hospital financial responsibility is critical for the purposes of cultural re-education.
However, it should be understood that implementing organizational change as part of strategic improvement always involves risks. The collection of statistics and information must be accompanied by transparency because the punitive relationship between the clinic and UHC implies excellent accountability. At the same time, clinical companies must agree to disclose this data to UHC and ensure its complete confidentiality under HIPAA. Finally, this requires upgrading the patient interaction system to ensure that client evaluations are collected smoothly and handled correctly.
Value Proposition for Change Management
As a summary of the previous two sections, it seems considerably clear that UHC needs organizational change that will optimize the current agenda and, on average, improve the medical culture. Such a value proposition is the implementation of training programs for the company’s clinical staff and clients. This solution will qualitatively increase the average awareness of patients not only about the probability of HACs but also about the rules of action in case of such an extraordinary situation (Patel et al., 2015). For company employees, the training should be implemented in order to increase their competence and remind them of the penalties imposed by the UHC if the clinic commits many medical errors (Van et al., 2018). This solution is strategically correct, although its implementation cannot but be accompanied by problems and risks.
For example, it is essential to get the full involvement of stakeholders; otherwise, the resources invested in training programs may not bring benefits. In addition, it is generally uncharacteristic for insurance companies to engage in training, therefore, an additional step would be to conduct marketing campaigns to entice more clients and employees. Finally, health care workers may not see the value in taking classes from UHC, which in some ways could be seen as the enemy. Therefore, the leadership of the two companies may enter into strategic partnerships in which, if the training is successful, the clinical companies can reduce fines.
Legal & Ethical Principles & Mission, Vision, Values
While recognizing concern for social well-being as one of UHC’s top priorities, it is critical to separately emphasize the critical ethical and legal challenges that a change implementation program may face. UHC’s ultimate goal, as encapsulated in its mission statement, directly affects, or to be more precise, in some ways conflicts with, the interests of clinicians (Appold, 2013). Few companies are genuinely interested in third-party intervention, and in the case of UHC, the implementation of such practices may seem excessive. In this sense, it is critical for the insurance company to be fully transparent about its intentions, namely to improve the health care agenda by reducing errors (Code of ethics, 2020). The UHC acts as a judge, as it has the power to impose fines on clinics, but in a strategic engagement, this role must be replaced by a trusted partner and companion in achieving a common goal.
References
About us. (n.d.). UHC. Web.
Appold, K. (2013). Medicare penalties make hospital-acquired-infection solutions a priority. The Hospitalist, 1(9), 1-3.
Code of ethics. (2020). ASCE. Web.
HHC. (2013). Summary of the HIPAA privacy rule. HHS. Web.
Hospital-acquired conditions. (2020). CMS. Web.
HRRP. (2020). CMS. Web.
Patel, K. K., Wu, V. and Parker, R. (2015). Getting enrolled isn’t enough: The importance of teaching consumers how to use health insurance. Health Affairs. Web.
Richardson, D. (2015). Reducing HACs. MHE. Web.
UHC. (2021). Hospital acquired conditions policy, facility [PDF document]. Web.
Van de Geer, J., Veeger, N., Groot, M., Zock, H., Leget, C., Prins, J., & Vissers, K. (2018).
Multidisciplinary training on spiritual care for patients in palliative care trajectories improves the attitudes and competencies of hospital medical staff: Results of a quasi-experimental study. American Journal of Hospice and Palliative Medicine, 35(2), 218-228.